Management Considerations for Pediatric Oral Surgery and Oral

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 527

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Purpose

e

American Academy of Pediatric Dentistry

(AAPD)

intends this document to dene, describe clinical presentation,

and set forth general criteria and therapeutic goals for com-

mon pediatric oral surgery procedures and oral pathological

conditions.

Methods

Recommendations on management considerations for pediatric

oral surgery and oral pathology were developed by the

Council on Clinical Aairs and adopted in 2005.

is

document is a revision of the previous version, last revised in

2015.

It is based on a review of the current dental and med-

ical literature related to pediatric oral surgery, including a

search of the PubMed

MEDLINE

database using the terms:

pediatric AND oral surgery, oral pathology, extraction,

odontogenic infections, impacted canines, third molars,

supernumerary teeth, mesiodens, mucocele, eruption cyst,

eruption hematoma, gingival keratin cysts, Epstein pearls,

Bohn’s nodules, congenital epulis of newborn, dental lamina

cysts, natal teeth, neonatal teeth, squamous papilloma, verruca

vulgaris, irritation fibroma, recurrent aphthous stomatitis,

localized juvenile spongiotic gingival hyperplasia, and pyogenic

granuloma; fields: all; limits: within the last 10 years, humans,

English, clinical trials. Papers for review were chosen from

the list of articles matching these criteria and from references

with selected articles. When data did not appear sufficient

or were inconclusive, recommendations were based upon

expert and/or consensus opinion by experience researchers

and clinicians. In addition, the manual Parameters of Care:

Clinical Practice Guidelines for Oral and Maxillofacial Surgery,

developed by the American Association of Oral and Maxil-

lofacial Surgeons (AAOMS), was consulted.

General considerations

Surgery performed on pediatric patients involves special

considerations unique to this population. Several critical issues

deserve to be addressed.

Preoperative considerations

Informed consent

Before any surgical procedure, informed consent must be

obtained from the parent or legal guardian. For more infor-

mation, refer to AAPD's Informed Consent.

ABBREVIATIONS

AAOMS:

American Association of Oral and Maxillofacial Surgeons.

AAPD: American Academy of Pediatric Dentistry. HPV:

Human

papilloma virus. VKDB:

Vitamin K deficiency bleeding.

Latest Revision

2020

Management Considerations for Pediatric Oral

Surgery and Oral Pathology

How to Cite: American Academy of Pediatric Dentistry. Management

considerations for pediatric oral surgery and oral pathology. The

Reference Manual of Pediatric Dentistry. Chicago, Ill.: American

Academy of Pediatric Dentistry; 2023:527-36.

Abstract

This best practice deﬁnes, describes clinical presentation, and establishes criteria and therapeutic goals for common pediatric oral surgery

procedures and oral pathological conditions. Pediatric oral surgery requires special considerations such as parental consent, knowledge

of developing anatomy and dentition, potential for adverse effects on growth, behavior guidance. and peri- and postoperative manage-

ment. Odontogenic infections usually are managed with pulp therapy, extraction, or incision and drainage. However, cases with systemic

manifestations require antibiotic therapy. Extraction of erupted, unerupted, impacted, and supernumerary teeth are discussed with emphasis

on a careful approach to avoid injury to adjacent teeth, permanent successors, and other hard and soft tissues. Considerations for surgical

correction of frenulum attachments are reviewed. Guidance is provided for biopsies, a procedure which can establish a deﬁnitive diagnosis

for most oral lesions. Common lesions in infants include Epstein pearls, Bohn nodules, and dental lamina cysts, and rare lesions include

congenital epulis of the newborn and melanotic neuroectodermal tumor of infancy. Management of these lesions and natal and neonatal

teeth is reviewed. Oral lesions in children and adolescents including eruption cysts, mucoceles, recurrent aphthous stomatitis, and pyogenic

granuloma also are addressed. While most lesions are mucosal conditions, developmental anomalies, or inﬂammatory lesions, practitioners

should be vigilant for neoplastic diseases.

This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and

Scientiﬁc Affairs to offer updated information and guidance on management considerations for pediatric oral surgery and oral pathology.

KEYWORDS: DIAGNOSIS; ORAL; ORAL SURGICAL PROCEDURES; PATHOLOGY; TOOTH EXTRACTION

528 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Medical evaluation

Important considerations in treating a pediatric patient include

obtaining a thorough medical history, obtaining appropriate

medical and dental consultations, anticipating and preventing

emergency situations, and being prepared to treat emergency

situations.

Dental evaluation

It is important to perform a thorough clinical and radiographic

preoperative evaluation of the dentition as well as a clinical

examination of extraoral and intraoral soft tissues.

5-7

Radio-

graphs can include intraoral lms and extraoral imaging if the

area of interest extends beyond the dentoalveolar complex.

Surgery involving the maxilla and mandible of young patients

is complicated by the presence of developing tooth follicles.

Knowledge of the anatomy of a child’s developing maxilla and

mandible and the avoidance of injury to the dental follicles

can prevent complications.

To minimize the negative eects

of surgery on the developing dentition, careful planning

using radiographs, tomography,

cone beam computed tomo-

graphy,

and/or three-dimensional imaging techniques

necessary to provide valuable information to assess the presence,

absence, location, and/or quality of individual crown and root

development.

8,12,13

Growth and development

e potential for adverse eects on growth from injuries and/

or surgery in the oral and maxillofacial region markedly

increases the potential for risks and complications in the

pediatric population. Traumatic injuries involving the maxil-

lofacial region can adversely aect growth, development, and

function. erefore, a thorough evaluation of the growing

patient must be done before surgical interventions are per-

formed to minimize the risk of damage to the growing facial

complex.

Behavioral evaluation

Behavioral guidance of children in the operative and periopera-

tive periods presents a special challenge. Many children benet

from modalities beyond local anesthesia and nitrous oxide/

oxygen inhalation to minimize their anxiety.

4,14

Management

of children under sedation or general anesthesia requires

extensive training and expertise.

15,16

Special attention should be

given to the assessment of the social, emotional, and psycho-

logical status and cognitive level of the pediatric patient prior

to surgery.

Children have many unvoiced fears concerning

the surgical experience, and their psychological management

requires that the dentist be cognizant of their emotional

status. Answering questions concerning the surgery is impor-

tant and should be done in the presence of the parent.

Peri- and postoperative considerations

Metabolic management of children following surgery fre-

quently is more complex than that of adults. Special consider-

ation should be given to caloric intake, uid and electrolyte

management, and blood replacement. Comprehensive man-

agement of the pediatric patient following extensive oral and

maxillofacial surgery usually is best accomplished in a facility

that has expertise and experience in the management of young

patients (i.e., a children’s hospital).

Recommendations

Odontogenic infections

In children, odontogenic infections may involve more than

one tooth and usually are due to caries lesions, periodontal

problems, pathology (e.g., dens invaginatus), or a history of

trauma.

17,18

Untreated odontogenic infections can lead to pain,

difficulty eating or drinking, abscess, cellulitis, septicemia,

airway compromise, and life-threatening infections.

Facial

cellulitis results from unresolved abscess that has spread to

cutaneous or subcutaneous soft tissue planes in the head and

neck region.

In these children, dehydration is a signicant

consideration; prompt treatment of the source of infection is

imperative.

With infections of the upper portion of the face, patients

usually complain of facial pain, fever, and malaise.

Care must

be taken to rule out sinusitis or non-odontogenic infections,

as symptoms may mimic an odontogenic infection. Occasionally

in upper face infections, it may be difficult to find the true

cause.

Infections of the lower face usually involve pain, swelling,

and trismus.

3,17

ey frequently are associated with teeth, skin,

local lymph nodes, and salivary glands.

Most odontogenic

infections occur in the upper face; however, infections in the

mandibular region are more frequent in older children.

Most odontogenic infections can be managed with pulp

therapy, extraction, or incision and drainage.

Infections of

odontogenic origin with systemic manifestations (e.g., elevated

temperature [102 to 104 degrees Fahrenheit], facial cellulitis,

diculty in breathing or swallowing, fatigue, nausea) require

antibiotic therapy.

Severe but rare complications of odonto-

genic infections include cavernous sinus thrombosis and

Ludwig’s angina.

17,19

ese conditions can be life threatening

and may require immediate hospitalization with intravenous

antibiotics, incision and drainage, and referral/consultation

with an oral and maxillofacial surgeon.

17,19

Extraction of erupted teeth

Maxillary and mandibular anterior teeth

Most primary and permanent maxillary and mandibular central

incisors, lateral incisors, and canines have conical single roots.

In most cases, extraction of anterior teeth is accomplished

with a rotational movement due to their single root

anatomy.

However, there have been reported cases of ac-

cessory roots observed in primary canines.

21,22

Radiographic

examination is helpful to identify dierences in root anatomy

prior to extraction.

Care should be taken to avoid placing

any force on adjacent teeth that could become luxated or

dislodged easily due to their root anatomy.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 529

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Maxillary and mandibular molars

Primary molars have roots that are smaller in diameter and

more divergent than permanent molars. Root fracture in

primary molars is not uncommon due to these characteristics

as well as the potential weakening of the roots caused by the

eruption of their permanent successors.

Prior to extraction,

the relationship of the primary roots to the developing suc-

cedaneous tooth should be assessed. To avoid inadvertent

extraction or dislocation of or trauma to the permanent

successor, pressure should be avoided in the furcation area or

the tooth may need to be sectioned to protect the developing

permanent tooth.

Molar extractions are accomplished by using slow conti-

nuous palatal/lingual and buccal force allowing for the

expansion of the alveolar bone to accommodate the divergent

roots and reduce the risk of root fracture.

When extracting

mandibular molars, care should be taken to support the

mandible to protect the temporomandibular joints from

injury.

Fractured primary tooth roots

e presence of a root tip should not be regarded as a positive

indication for its removal. e dilemma to consider when

managing a retained primary tooth root is that removing the

root tip may cause damage to the succedaneous tooth, while

leaving the root tip may increase the chance for postopera-

tive infection and delay eruption of the permanent successor.

Radiographs can assist in the decision process. Expert opinion

suggests that if the fractured root tip can be removed easily,

it should be removed.

If the root tip is very small, located

deep in the socket, situated in close proximity to the permanent

successor, or unable to be retrieved after several attempts, it is

best left to be resorbed.

e parent must be informed and a

complete record of the discussion must be documented. e

patient should be monitored at appropriate intervals to eval-

uate for potential adverse eects.

Management of unerupted and impacted teeth

ere is a wide clinical spectrum of disorders of eruption in

both primary and permanent teeth in children. ese may

be syndromic or nonsyndromic and include ankyloses,

27-28

secondary retention,

tooth impaction, or primary failure of

eruption

. Clinically, it may be dicult to dierentiate be-

tween the various disruptions; however, there have been many

reports

30,31

to assist the clinician in making a diagnosis.

Increasing evidence supports a genetic etiology for some

eruption disruptions which may help in a denitive

diagnosis.

Management of unerupted teeth will depend on

whether the aected tooth is likely to respond to orthodontic

forces. If not, surgical extraction is the preferred treatment

option.

Impacted canines

Tooth impaction may occur due to a mechanical obstruction.

Permanent maxillary canines are second to third molars in

frequency of impaction.

Early detection of an ectopically

erupting canine through visual inspection, palpation, and

radiographic examination is important to maximize success of

an intervention.

Routine evaluation of patients in mid-mixed

dentition should involve identifying signs such as lack of ca-

nine bulges and asymmetry in pattern of exfoliation. Abnormal

angulation or ectopic eruption of developing permanent cus-

pids can be assessed radiographically.

When the cusp tip of

the permanent canine is just mesial to or overlaying the distal

half of the long axis of the root of the permanent lateral incisor,

canine palatal impaction usually occurs.

Extraction of the

primary canines is the treatment of choice to correct palatally

displaced canines or to prevent resorption of adjacent teeth.

One study showed that 78 percent of ectopically erupting

permanent canines normalized within 12 months after removal

of the primary canines; 64 percent normalized when the

starting canine position overlapped the lateral incisor by more

than half of the root; and 91 percent normalized when the

starting canine position overlapped the lateral incisor by less

than half of the root.

If no improvement in canine position

occurs in a year, surgical and/or orthodontic treatment were

suggested.

32,33

A Cochrane review

and a systematic review

reported no evidence to support extraction of primary canines

to facilitate eruption of ectopic permanent maxillary canines.

A prospective randomized clinical trial demonstrated that

extraction of primary canines is an eective measure to correct

palatally displaced maxillary canines and is more successful in

children with an early diagnosis.

Consultation between the

practitioner and an orthodontist may be useful in the nal

treatment decision.

ird molars

Panoramic or periapical radiographic examination is indicated

in late adolescence to assess the presence, position, and devel-

opment of third molars.

e AAOMS recommends that a

decision to remove or retain third molars should be made

before the middle of the third decade.

Evidence-based research

supports the removal of third molars when pathology (e.g.,

cysts or tumors, caries, infection, pericoronitis, periodontal

disease, detrimental changes of adjacent teeth or bone) is asso-

ciated and/or the tooth is malpositioned or nonfunctional

(i.e., an unopposed tooth).

37-39

ere is no evidence to

support

37-40

or refute

the prophylactic removal of disease-free

impacted third molars. Factors that increase the risk for

surgical complications (e.g., coexisting systemic conditions,

location of peripheral nerves, history of temporomandibular

joint disease, presence of cysts or tumors)

38,39

and position

and inclination of the molar in question

should be assessed.

e age of the patient is only a secondary consideration.

Referral to an oral and maxillofacial surgeon for consultation

and subsequent treatment may be indicated. When a decision

is made to retain impacted third molars, they should be

monitored for change in position and/or development of

pathology, which may necessitate later removal.

530 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Supernumerary teeth

Supernumerary teeth and hyperdontia are terms to describe

an excess in tooth number. Supernumerary teeth are thought

to be related to disturbances in the initiation and proliferation

stages of dental development.

Although some supernumerary

teeth may be syndrome-associated (e.g., cleidocranial dysplasia)

or of familial inheritance pattern, most supernumerary teeth

occur as isolated events.

Supernumerary teeth can occur in either the primary or

permanent dentition.

21,42,43

In 33 percent of the cases, a super-

numerary tooth in the primary dentition is followed by the

supernumerary tooth complement in the permanent denti-

tion.

Reports in incidence of supernumerary teeth can be

as high as three percent, with the permanent dentition being

aected ve times more frequently than the primary dentition

and males being aected twice as frequently as females.

Supernumerary teeth will occur 10 times more often in

the maxillary arch versus the mandibular arch.

Approxi-

mately 90 percent of all single tooth supernumerary teeth are

found in the maxillary arch, with a strong predilection to the

anterior region.

21,42

e maxillary anterior midline is the most

common site, in which case the supernumerary tooth is known

as a mesiodens; the second most common site is the maxillary

molar area, with the tooth known as a paramolar.

21,42

A me-

siodens can be suspected if there is an asymmetric eruption

pattern of the maxillary incisors, delayed eruption of the

maxillary incisors with or without any overretained primary

incisors, or ectopic eruption of a maxillary incisor.

The

diagnosis of a mesiodens can be conrmed with radiographs,

including occlusal, periapical, or panoramic lms,

or com-

puted tomography.

9,10

ree-dimensional information needed

to determine the location of the mesiodens or impacted tooth

can be obtained by taking two periapical radiographs using

either two projections taken at right angles to one another or

the tube-shift technique (buccal object rule or Clark’s rule)

or by cone beam computed tomography.

10,12,13

Complications of supernumerary teeth can include delayed

and/or lack of eruption of the permanent tooth, crowding,

resorption of adjacent teeth, dentigerous cyst formation, peri-

coronal space ossification, and crown resorption.

42,48

Early

diagnosis and appropriately timed treatment are important in

the prevention and avoidance of these complications. Because

only 25 percent of all mesiodens erupt spontaneously, surgical

management often is necessary.

44,49

A mesiodens that is conical

in shape and is not inverted has a better chance for eruption

than a mesiodens that is tubular in shape and is inverted.

e

treatment objective for a nonerupting permanent mesiodens

is to minimize eruption problems for the permanent incisors.

Surgical management will vary depending on the size, shape,

and number of supernumeraries and the patient’s dental

development.

The treatment objective for a nonerupting

primary mesiodens diers in that the removal of these teeth

usually is not recommended, as the surgical intervention may

disrupt or damage the underlying developing permanent

teeth.

Erupted primary tooth mesiodens typically are left

to shed normally upon the eruption of the permanent

dentition.

Extraction of an unerupted primary or permanent mesio-

dens is recommended during the mixed dentition to allow the

normal eruptive force of the permanent incisor to bring itself

into the oral cavity.

Waiting until the adjacent incisors have

at least two-thirds root development will present less risk to

the developing teeth but still allow spontaneous eruption of

the incisors.

In 75 percent of the cases, extraction of the

mesiodens during the mixed dentition results in spontaneous

eruption and alignment of the adjacent teeth.

50,51

If the adja-

cent teeth do not erupt within six to 12 months, surgical

exposure and orthodontic treatment may be necessary to aid

their eruption.

45,47

Frenulum attachments

Frenulum attachments and their role in oral function increas-

ingly have become topics of interest among a variety of health

care specialists. Ankyloglossia (tongue-tie) and hypertrophic/

restrictive maxillary frenula have been implicated in diculties

breastfeeding

, incorrect speech articulation

54,55

, caries forma-

tion

56,57

, gingival recession

, and aberrant skeletal growth

Studies have shown dierences in treatment recommendations

among pediatricians, otolaryngologists, lactation consultants,

speech pathologists, surgeons, and dental specialists.

54,60-66

Clear

indications and timing of surgical treatment remain controver-

sial due to lack of consensus regarding accepted anatomical and

diagnostic criteria for degree of restriction and relative impact

on growth, development, feeding, or oral motor function.

54,60-66

When indicated, frenuloplasty/frenotomy (various methods

to release the frenulum and correct the anatomic situation) or

frenectomy (simple cutting of the frenulum) may be a success-

ful approach to alleviate the problem.

54,60,65,67

Each of these

procedures involves surgical incision, establishing hemostasis,

and wound management.

Dressing placement or the use of

antibiotics is not necessary.

Recommendations include

maintaining a soft diet, regular oral hygiene, and analgesics

as needed.

e use of electrosurgery or laser technology for

frenectomies has demonstrated a shorter operative working

time, a better ability to control bleeding, reduced intra- and

postoperative pain and discomfort, fewer postoperative

complications (e.g., swelling, infection), no need for suture

removal, and increased patient acceptance.

62,69,70

ese proce-

dures require extensive training as well as skillful technique

and patient management.

54,60,65,67,71-75

Pediatric oral pathology

A wide spectrum of oral lesions occurs in children and ad-

olescents, including soft and hard tissue lesions of the oral

maxillofacial region. ere is limited information on the pre-

valence of oral lesions in the pediatric population. e largest

epidemiologic studies in the United States place the prevalence

rate in children at four to 10 percent with the exclusion of

infants.

76,77

Although the vast majority of these lesions represent

mucosal conditions, developmental anomalies, and reactive

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 531

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

or inflammatory lesions, it is imperative to be vigilant for

neoplastic diseases.

Regardless of the age of the child, it is important to estab-

lish a working diagnosis for every lesion. This is based on

obtaining a thorough history, assessing the risk factors and

documenting the clinical signs and symptoms of the lesion.

Based on these facts, a list of lesions with similar characteris-

tics is rank ordered from most likely to least likely diagnosis.

e entity that is judged to be the most likely disease becomes

the working diagnosis and determines the initial management

approach.

For most oral lesions, a denitive diagnosis is best made by

performing a biopsy. By definition, a biopsy is the removal

of a piece of tissue from a living body for diagnostic study

and is considered the gold standard of diagnostic tests.

e

two most common biopsies are the incisional and excisional

types. Excisional biopsies usually are performed on small

lesions, less than one centimeter in size, for the total removal

of the aected tissue. An incisional biopsy is performed when

a malignancy is suspected, the lesion is large in size or diuse

in nature, or a multifocal distribution is present. Multiple

incisional biopsies may be indicated for diffuse lesions in

order to obtain a representative tissue sample. Fine needle

aspiration, the cytobrush technique, and exfoliative cytology

may assist in making a diagnosis, but they are considered

adjunctive tests because they do not establish a definitive

diagnosis.

79,80

It is considered the standard of care that any tissue

removed from the oral and maxillofacial region be submitted

for histopathologic examination.

Exceptions to this rule in-

clude carious teeth that do not have soft tissue attached, extirpated

pulpal tissue, and clinically normal tissue, such as tissue from

gingival recontouring.

Gross description of all tissue that is

removed should be entered into the patient record. In general,

a soft tissue biopsy should be performed when a lesion persists

for greater than two weeks despite removal of the suspected

causative factor or empirical drug treatment. It is also imper-

ative to submit hard or soft tissue for evaluation to a pathologist

if the differential diagnosis includes at least one significant

disease or neoplasm. Histopathologic examination not only

furnishes a definitive diagnosis, but it provides information

about the clinical behavior and prognosis and determines the

need for additional treatment or follow-up. Another valuable

outcome is that it allows the clinician to deliver evidence-based

medical/dental care, increasing the likelihood for a positive

result.

Furthermore, it presents important documentation

about the lesion for the patient record, including the pro-

cedures taken for establishing a diagnosis.

Many oral biopsies are within the scope of practice for a

pediatric dentist to perform. If the tissue is excised, the follow-

ing steps should be taken for optimum results:

78-81

1. select the most representative lesion site and not the area

that is the most accessible.

2. remove an adequate amount of tissue. If the biopsy is too

small or too supercial, a diagnosis may be compromised.

3. avoid crushing or distorting the tissue. Damage is most

often observed from the forces of the tissue forceps,

tearing the tissues or overheating the tissue from the use

of electrosurgery or laser removal.

4. immediately place the tissue in a xative, which for most

samples is 10 percent formalin. It is critical not to dilute

the fixative with water or other liquids because tissue

autolysis will render the sample nondiagnositic.

5. proper identification of the specimen is essential. The

formalin container should be labelled with the name

of the patient and the location. Multiple tissue samples

from different locations should not be placed in the

same container, unless they are uniquely identied, such

as tagged with a suture.

6. complete the surgical pathology form including patient

demographics, the submitting dentist’s name and address,

and a brief but accurate history. It is important to have

legible records so that the diagnosis is not delayed.

Clinical photographs and radiographs often are very

useful for correlating the microscopic ndings.

Worldwide, the most frequently oral biopsied lesions in

children include

• mucocele;

• brous lesions;

• pyogenic granuloma;

• dental follicle;

• human papillomavirus (HPV) lesion;

• chronic inammation;

• giant cell lesions (soft tissue);

• hyperkeratosis;

• peripheral ossifying fibroma;

• gingivitis;

• gingival hyperplasia;

• hemangioma;

• ulcer;

• lymphangioma;

• sialadentis;

• Burkitt’s lymphoma;

• melanotic macule;

• pleomorphic adenoma;

• nevus; and

• neurobroma.

Lesions of the newborn

Palatal cysts of the newborn include Epstein pearls and Bohn

nodules. These cysts are found in up to 85 percent of new-

borns.

53,83-90

Epstein pearls occur in the median palatal raphe

area

53,83-85

as a result of trapped epithelial remnants along the

line of fusion of the palatal halves.

49,51

Bohn nodules are

remnants of salivary gland epithelium and usually are found

on the buccal and lingual aspects of the ridge, away from the

midline.

83,85

Gingival cysts of the newborn, or dental lamina

cysts, are found on the crests of the dental ridges, and are most

commonly are seen bilaterally in the region of the rst primary

532 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

molars.

They result from remnants of the dental lamina.

Palatal and gingival cysts of the newborn typically present as

asymptomatic one to three millimeter nodules or papules.

They are smooth, whitish in appearance, and filled with

keratin.

83,84

No treatment is required, as these cysts usually

disappear during the rst three months of life.

53,83

Congenital epulis of the newborn

Congenital epulis of the newborn, also known as granular

cell tumor or Neumann’s tumor, is a rare benign tumor seen

only in newborns.

This lesion is typically a protuberant

mass arising from the gingival mucosa. It is most often

found on the anterior maxillary ridge.

86,87

Patients typically

present with feeding and/or respiratory problems.

Congenital

epulis has a marked predilection for females at 8:1 to 10:1.

86-88

Treatment normally consists of surgical excision.

86-88

The

newborn usually heals well, and no future complications or

treatment should be expected. Congenital epulis never recurs

after excision.

There have been reports of spontaneous

regression of untreated congenital epulis.

88,91

Melanotic neuroectodermal tumor of infancy

Melanotic neuroectodermal tumor of infancy is a rare occur-

rence that develops during the rst year of life.

is lesion

may be present at birth. It occurs in the anterior maxilla 70

percent of the time.

Less frequently, melanotic neuroecto-

dermal tumor of infancy occurs in the skull, mandible,

epididymis and testis, and brain.

83,88

e classic presentation

is a bluish or black rapidly expanding mass of the anterior

maxilla. Radiographic findings include an ill-defined

unilocular radiolucency with the displacement of tooth buds.

ere can be a oating tooth appearance.

Surgical excision is

required, and there is a 20 percent recurrence rate. Although

this is a benign lesion, seven percent of reported cases have

behaved malignantly resulting in metastasis and death.

Natal and neonatal teeth

Natal and neonatal teeth can present a challenge when deciding

on appropriate treatment. Natal teeth have been defined as

those teeth present at birth, and neonatal teeth are those that

erupt during the first 30 days of life.

92,93

The occurrence of

natal and neonatal teeth is rare; the incidence varies from

1:1,000 to 1:30,000.

92,93

e teeth most often aected are the

mandibular primary incisors.

In most cases, anterior natal

and neonatal teeth are part of the normal complement of the

dentition.

92,93

Natal or neonatal molars have been identied in

the posterior region and may be associated with systemic condi-

tions or syndromes (e.g., Peer syndrome, histiocytosis X).

94-96

Although many theories exist as to why the teeth erupt prema-

turely, currently no studies conrm a causal relationship with

any of the proposed theories. e supercial position of the

tooth germ associated with a hereditary factor seems to be the

most accepted possibility.

If the tooth is not excessively mobile or causing feeding

problems, it should be preserved and maintained in a healthy

condition if possible.

93,95,96

Close monitoring is indicated to

ensure that the tooth remains stable and is not an aspiration

risk to the infant.

Riga-Fede disease is a condition caused by the natal or

neonatal tooth rubbing the ventral surface of the tongue

during feeding, leading to ulceration.

75,92

Failure to diagnose

and properly treat this lesion can result in dehydration and

inadequate nutritional intake for the infant.

Treatment

should be conservative and focus on creating round, smooth

incisal edges.

93-96

If conservative treatment does not correct the

condition, extraction is the treatment of choice.

93-96

An important consideration when deciding to extract a natal

or neonatal tooth is the potential for hemorrhage. Extraction

is contraindicated in newborns due to risk of hemorrhage.

Unless the child is at least 10 days old, consultation with the

pediatrician regarding adequate hemostasis may be indicated

prior to extraction of the tooth. In particular, infants may be

at risk for vitamin K deciency bleeding (VKDB) if they did

not receive a dose of vitamin K shortly after birth (within six

hours of birth).

Infants can be at risk for VKDB until the

age of six months if they do not receive a vitamin K injection.

Lesions occurring in children and adolescents

Eruption cyst (eruption hematoma)

The eruption cyst is a soft tissue cyst that results from a

separation of the dental follicle from the crown of an erupting

tooth.

83,99

Fluid accumulation occurs within this created fol-

licular space.

85,89,100

Eruption cysts most commonly are found in

the mandibular molar region.

Color of these lesions can range

from normal to blue-black or brown, depending on the amount

of blood in the cystic uid.

85,89,100

e blood is secondary to

trauma. If trauma is intense, these blood-lled lesions some-

times are referred to as eruption hematomas.

85,89,100

Because the

tooth erupts through the lesion, no treatment is necessary.

85,89,100

If the cyst does not rupture spontaneously or the lesion becomes

infected, the roof of the cyst may be opened surgically.

85,89

Mucocele

e mucocele is a common lesion in children and adolescents

resulting from the rupture of a minor salivary gland excretory

duct, with subsequent leakage of mucin into the adjacent

connective tissues that later may be surrounded in a brous

capsule.

83,85,99-101

Most mucoceles are well-circumscribed bluish

translucent fluctuant swellings that are firm to palpation,

although deeper and long-standing lesions may range from

normal in color to having a whitish keratinized surface.

85,99,100

Mucoceles most frequently are observed on the lower lip, usually

lateral to the midline.

Mucoceles also can be found on the

buccal mucosa, ventral surface of the tongue, retromolar region,

and oor of the mouth (ranula).

99-101

Supercial mucoceles and

some other mucoceles are short-lived lesions that burst spon-

taneously, leaving shallow ulcers that heal within a few

days.

85,100

Local mechanical trauma to the minor salivary gland

is often the cause of rupture.

50,53,86,87

Many lesions, however,

require treatment to minimize the risk of recurrence.

85,100

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 533

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Squamous papilloma

Squamous papilloma is a benign lesion caused by HPV types 1

and 6.

Squamous papilloma presents as soft painless, pink

to white, pedunculated (stalked) lesions. The surface may

display multiple fingerlike projections and may have a

cauliflower like appearance.

83,102,103

These lesions can occur

anywhere in the oral cavity, but the tongue, lips, and soft

palate are the most common sites.

103

Squamous papilloma

generally occurs in adulthood, but 20 percent have been

noted prior to age 20.

Although they are viral in origin,

the infectivity is low.

83,102

Squamous papilloma do not have

malignant potential.

103

Excision is the treatment of choice,

and recurrence is uncommon.

83,103

Verruca vulgaris

Verruca vulgaris, or the common wart, is a lesion induced by

HPV type 2 and generally found on the skin of the hand.

102

Finger or thumb sucking can cause autoinoculation resulting

in the development of intraoral lesions.

102

Verruca vulgaris is

similar in appearance to the squamous papilloma. This le-

sion can be sessile (broad based) or pedunculated and can

display a rough bumpy surface.

103

Verruca vulgaris can be

found on the lips, tip of tongue, and labial mucosa.

ere is

no risk of malignant transformation.

Excision of the entire

lesion is recommended and recurrence is uncommon.

103

Irritation broma

The irritation fibroma is a reactive lesion occurring as a re-

sponse to chronic trauma of the mucosa. e irritation broma

presents as a rm nontender pink nodule and is composed of

fibrous connective tissue.

103

The lesion does not exceed two

millimeters in diameter.

104

e irritation broma can be found

on buccal and labial mucosa, the tongue, and attached gingiva.

Excisional biopsy is recommended. These can reoccur if the

source of the irritation is not removed.

103,104

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis is one of the most common oral

lesions, occurring in 20-30 percent of children.

Recurrent

aphthous stomatitis is caused by a T-cell mediated immu-

nologic reaction to a triggering agent.

105

Three variants of

aphthous ulcers are recognized:

1. Minor aphthous ulcerations. Minor aphthous ulcerations

are the most common form, accounting for almost 80

percent of aphthous ulcers.

105

They have a yellowish-

white membrane and are surrounded by an erythematous

halo. ese ulcers are three to 10 millimeters in diameter.

Minor aphthous ulcers occur on nonkeratinized mu-

cosa.

105

One to ve ulcers often present during a single

outbreak, and they heal in seven to 14 days without

scarring.

106

2. Major aphthous ulcerations. Major aphthous ulcerations

are larger and deeper and have a longer duration than

the minor aphthous ulcer. ese occur most commonly

on the labial mucosa, soft palate, and the tonsillar

fauces.

105

The major aphthous ulcer can take up to six

weeks to heal with potential scarring.

105

3. Herpetiform aphthous ulcerations. Herpetiform aphthous

ulcerations can occur on any intraoral site.

106

As many as

100 small ulcerations can be present in a single occur-

rence.

105

e ulcerations may resemble primary herpetic

stomatitis. These ulcerations may coalesce to form a

larger ulceration.

105

Herpetiform aphthous ulcers heal

within seven to 10 days, but recurrences are frequent.

106

Aphthous ulcers may be treated with topical anesthetics

for relief of pain. Topical and systemic steroids, chlorhexidine

rinses, and laser treatments can be used to manage these

lesions.

Localized juvenile spongiotic gingival hyperplasia

Localized juvenile spongiotic gingival hyperplasia was originally

known as puberty gingivitis.

107

It is thought to be an isolated

patch of sulcular or junctional epithelium that is subjected to

local factors such as mouth breathing or orthodontic appli-

ances.

The lesion presents as an isolated bright red velvety

patch or enlargement of anterior facial gingiva. This lesion

bleeds easily and does not respond to oral hygiene measures.

ere is a female predilection.

Most lesions occur under the

age of 20, with the median age at diagnosis being 12 years.

107

Excision is the treatment of choice, and up to 16 percent will

recur.

Pyogenic granuloma

Pyogenic granuloma is a painless smooth or lobulated vascular

lesion. e pyogenic granuloma is usually ulcerated and bleeds

easily.

83,107

is lesion can occur at any age but is most common

in children and young adults. ere is a female predilection,

and the pyogenic granuloma can occur in up to ve percent

of pregnancies.

108

The pyogenic granuloma is thought to be

an exuberant tissue response to a local irritant or trauma.

108

Pyogenic granuloma most commonly occurs on maxillary

anterior attached gingiva (75 percent) but can be found on

tongue, lower lip, or buccal mucosa.

108

Treatment is complete

excision with the removal of the source of irritant.

83,108

This

lesion can recur in three to 15 percent of cases.

References

1. American Academy of Pediatric Dentistry. Pediatric oral

surgery. Pediatr Dent 2005;27(Suppl):158-64.

2. American Academy of Pediatric Dentistry. Management

considerations for pediatric oral surgery and oral pathol-

ogy. Pediatr Dent 2015;37(special issue):279-88.

3. American Association of Oral and Maxillofacial Surgeons.

Dentoalveolar Surgery. In: Parameters of Care: Clinical

practice guidelines for oral and maxillofacial surgery

(AAOMS ParCare 2017 Ver 6). J Oral Maxillofac Surg

2017;75(8)Suppl 1:e50-73.

References continued on the next page.

534 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

4. American Academy of Pediatric Dentistry. Informed con-

sent. e Reference Manual of Pediatric Dentistry. Chicago,

Ill.: American Academy of Pediatric Dentistry; 2020:470-3.

5. Adewumi AO. Oral surgery in children. In: Nowak AJ,

Christensen JR, Mabry TR, Townsend JA, Wells MH, eds.

Pediatric Dentistry Infancy through Adolescence. 6th ed.

St Louis, Mo.: Elsevier; 2019:399-409.

6. Kaban L, Troulis M. Preoperative assessment of the pediatric

patient. In: Pediatric Oral and Maxillofacial Surgery.

Philadelphia, Pa.: Saunders; 2004:3-19.

7. American Academy of Pediatric Dentistry. Prescribing

dental radiographs for infants, children, adolescents,

and persons with special health care needs. e Reference

Manual of Pediatric Dentistry. Chicago, Ill.: American

Academy of Pediatric Dentistry; 2020:248-51.

8. Murray DJ, Chong DK, Sandor GK, Forrest CR. Denti-

gerous cyst after distraction osteogenesis of the mandible.

J Craniofac Surg 2007;18(16):1349-52.

9. Ramesh A. Panoramic imaging. In: Mallya SM, Lam WN,

eds. Oral Radiology: Principles and Interpretation. 8th

ed. St. Louis, Mo.: Elsevier; 2019:132-50.

10. Scarfe WC, Farman AG. Cone-beam computed tom-

ography volume preparation. In: Mallya SM, Lam WN,

eds. White and Pharoah’s Oral Radiology: Principles and

nterpretation. 8th ed. St. Louis, Mo.: Elsevier; 2019:165-80.

11. Mallya SM. Other imaging modalities. In: Mallya SM,

Lam WN, eds. White and Pharoah’s Oral Radiology:

Principles and Interpretation. 8th ed. St. Louis, Mo.:

Elsevier; 2019:2218-38.

12. Katheria BC, Kau CH, Tate R, Chen JW, English J, Bouquot

J. Eectiveness of impacted and supernumerary tooth diag-

nosis from traditional radiography versus cone beam

computed tomography. Pediatr Dent 2010;32(4):304-9.

13. Serrant PS, McIntyre GT, Thomson DJ. Localization of

ectopic maxillary canines–Is CBCT more accurate than

conventional horizontal or vertical parallax? J Orthod 2014;

41(1):13-8.

14. Ferneini EM, Bennett JD. Oral surgery for the pediatric

patient. In: Dean JA, ed. McDonald and Avery’s Dentistry

for the Child and Adolescent, 10th ed. St Louis, Mo.:

Elsevier; 2016:627-44.

15. American Academy of Pediatric Dentistry. Use of anes-

thesia providers in the administration of oce-based deep

sedation/general anesthesia to the pediatric dental patient.

e Reference Manual of Pediatric Dentistry. Chicago, Ill.:

American Academy of Pediatric Dentistry; 2019:327-30.

16. Kaban L, Troulis M. Deep sedation for pediatric patients.

In: Pediatric Oral and Maxillofacial Surgery. Philadelphia,

Pa.: Saunders; 2004:86-99.

17. Kaban L, Troulis M. Infections of the maxillofacial region.

n: Pediatric Oral and Maxillofacial Surgery. Philadelphia,

Pa.: Saunders; 2004:171-86.

18. Seow W. Diagnosis and management of unusual dental

abscesses in children. Aust Dent J 2003;43(3):156-68.

19. Baker S, Parico L. Pathologic paediatric conditions associ-

ated with a compromised airway. Int J Paediatr Dent 2010;

20(2):102-11.

20. ikkurissy S, Rawlins JT, Kumar A, et al. Rapid treatment

reduces hospitalization for pediatric patients with

odontogenic-based cellulitis. Am J Emerg Med 2010;28

(6):668-72.

21. Regezi J, Sciubba J, Jordan R. Abnormalities of teeth. In:

Oral Pathology: Clinical-Pathologic Correlations. 7th ed. St.

Louis, Mo.: Elsevier; 2017:373-88.

22. Mochizuki K, Ohtawa Y, Kubo S, Machida Y, Yakushiji M.

Bifurcation, bi-rooted primary canines: A case report. Int

J Paediatr Dent 2001;11(5):380-5.

23. Andersson L, Blomlöf L, Lindskog S, Feiglin B,

Hammarström L. Tooth ankylosis. Clinical, radiographic

and histological assessments. Int J Oral Surg 1984;13(5):

423-31.

24. American Academy of Pediatric Dentistry. Management of

developing dentition and occlusion in pediatric dentistry.

The Reference Manual of Pediatric Dentistry. Chicago,

Ill.: American Academy of Pediatric Dentistry; 2020:

393-409.

25. Tieu LD, Walker SL, Major MP, Flores-Mir C. Management

of ankylosed primary molars with premolar successors: A

systematic review. J Am Dent Assoc 2013;144(6):602-11.

26. O’Connell AC, Torske KR. Primary failure of tooth

eruption: A unique case. Oral Surg Oral Med Oral Pathol

Oral Radiol Endod 1999;87(6):714-20.

27. Frazier-Bowers SA, Koehler KE, Ackerman JL, Prot WR.

Primary failure of eruption: Further characterization of a

rare eruption disorder. Am J Orthod Dentofacial Orthop

2007;131(5):578, e1-11.

28. Raghoebar GM, Boering G, Vissink A. Clinical, radiographic

and histological characteristics of secondary retention of

permanent molars. J Dent 1991;19(3):164-70.

29. Frazier-Bowers SA, Puranik CP, Mahaney MC. The

etiology of eruption disorders – Further evidence of a

‘genetic paradigm’. Semin Orthod 2010;16(3):180-5.

30. Rhoads SG, Hendricks HM, Frazier-Bowers SA. Estab-

lishing the diagnostic criteria for eruption disorders based

on genetic and clinical data. Am J Orthod Dentofacial

Orthop 2013;114(2):194-202.

31. Sharif MO, Parker K, Lyne A, Chia MSY. The

orthodontic-oral surgery interface part two: Diagnosis and

management of anomalies in eruption and transpositions.

Brit Dent J 2018;225(6);491-6.

32. Ericson S, Kurol J. Early treatment of palatally erupting

maxillary canines by extraction of the primary canines.

Eur J Orthod 1988;10(4):283-95.

33. Richardson G, Russel K. A review of impacted permanent

maxillary cuspids – Diagnosis and prevention. J Can Dent

Assoc 2000;66(9):497-501.

34. Parkin N, Benson P, Shah A, et al. Extraction of primary

(baby) teeth for unerupted palatally displaced permanent

canine teeth in children. Cochrane Database Syst Rev

2009;15(2):CD004621.

35. Naoumova J, Kurol J, Kjellberg H. A systematic review of

the interceptive treatment of palatally displaced maxillary

canines. Eur J Orthod 2011;33(2):143-9.

36. Bazargani F1, Magnuson A, Lennartsson B. Effect of

interceptive extraction of deciduous canine on palatally

displaced maxillary canine: A prospective randomized

controlled study. Angle Orthod 2014;84(1):3-10.

37. Song F, O’Meara S, Wilson P, Goldner S, Kleijnen J. e

eectiveness and cost-eectiveness of prophylactic removal

of wisdom teeth. Health Technol Assess 2000;4(1):1-55.

38. Haug R, Perrott D, Gonzalez M, Talwar R. e American

Association of Oral and Maxillofacial Surgeons age-related

third molar study. J Oral Maxillofac Surg 2005;63(8):

1106-14.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 535

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

39. Pogrel M, Dodson T, Swift J, et al. White paper on third

molar data. American Association of Oral and Maxillo-

facial Surgeons. March 2007. Available at: “https://www.

aaoms.org/docs/govt_aairs/advocacy_white_papers/white

_paper_third_molar_data.pdf”. Accessed July 24, 2020.

40. Friedman JW. e prophylactic extraction of third molars:

A public health hazard. Am J Public Health 2007;97(9):

1554-9.

41. Almendros-Marques N, Alaejos-Algarra E, Quinteros-

Borgarello M, Berini-Aytes L, Gay-Escoda C. Factors inu-

encing the prophylactic removal of asymptomatic impacted

lower third molars. Int J Oral Maxillofac Surg 2008;37(1):

29-35.

42. Neville BW, Damm DD, Allen CM, Chi AC. Abnormalities

of the teeth. In: Oral and Maxillofacial Pathology. 4th ed.

St. Louis, Mo.: Elsevier; 2016:49-110.

43. Dean JA. Managing the developing occlusion. In: Mc-

Donald and Avery’s Dentistry for the Child and Adolescent.

10th ed. St Louis, Mo.: Elsevier; 2016:415-78.

44. Taylor GS. Characteristics of supernumerary teeth in the

primary and permanent dentition. Trans Br Soc Study

Orthod 1970-71;57:123-8.

45. Primosch R. Anterior supernumerary teeth—Assessment

and surgical intervention in children. Pediatr Dent 1981;

3(2):204-15.

46. Tadinada A, Potluri. Dental anomalies. In: Mallya SM, Lam

EW, eds. White and Pharoah’s Oral Radiology: Principles

and Interpretation. 8th ed. St Louis, Mo.: Elsevier; 2019:

335-63.

47. Mallya SM, White S, Pharoah M. Projection geometry.

In: Mallya SM, Lam MN, eds. White and Pharoah’s Oral

Radiology: Principles and Interpretation. 8th ed. St. Louis,

Mo.: Mosby Elsevier; 2019:81-8.

48. Christensen JR, Fields HW Jr., Sheats RD. Treatment

planning and management of orthodontic problems. In:

Nowak AJ, Christensen JR, Mabry TR, Townsend JA, Wells

MH, eds. Pediatric Dentistry: Infancy through Adolescence.

6th ed. Philadelphia, Pa.: Elsevier; 2019:512-53.

49. Neville BW, Damm DD, White DK. Pathology of the

teeth. In: Color Atlas of Clinical Oral Pathology. 2nd ed.

Baltimore, Md.: Williams & Wilkins; 2003:58-60.

50. Russell K, Folwarczna M. Mesiodens: Diagnosis and man-

agement of a common supernumerary tooth. J Can Dent

Assoc 2003;69(6):362-6.

51. Howard R. The unerupted incisor. A study of the post-

operative eruptive history of incisors delayed in their

eruption by supernumerary teeth. Dent Pract Dent Rec

1967;17(9):332-41.

52. Giancotti A, Grazzini F, De Dominicis F, Romanini G,

Arcuri C. Multidisciplinary evaluation and clinical manage-

ment of mesiodens. J Clin Pediatr Dent 2002;26(3):233-7.

53. Neville BW, Damm DD, Allen CM, Chi AC. Develop-

mental defects of the oral and maxillofacial region. In: Oral

and Maxillofacial Pathology. 4th ed. St. Louis, Mo.: Elsevier;

2016:1-48.

54. Suter VG, Bornstein MM. Ankyloglossia: Facts and myths

in diagnosis and treatment. J Periodontol 2009;80(8):

1204-19.

55. Webb AN, Hao W, Hong P. e eect of tongue-tie divi-

sion on breastfeeding and speech articulation: A systematic

review. Int J Pediatr Otorhinolaryngol 2013;77(5):635-46.

56. Coryllos E, Genna CW, Salloum A. Congenital tongue-tie

and its impact on breastfeeding. Breastfeeding: Best for

baby and mother. Am Acad Pedia (newsletter) 2004;

Summer:1-7.

57. Kotlow L. The influence of the maxillary frenum on the

development and pattern of dental caries on anterior teeth

in breastfeeding infants: Prevention, diagnosis, and treat-

ment. J Hum Lact 2010;26(3):304-8.

58. John J, Weddell JA, Shin DE, Jones JJ. Gingivitis and

periodontal disease. In: JA Dean, ed. McDonald and Avery’s

Dentistry for the Child and Adolescent, 10th ed. St. Louis,

Mo.; Elsevier; 2016:243-73.

59. Geddes D, Langton D, Gollow I, Jacobs L, Hartmann P,

Simmer K. Frenulotomy for breastfeeding infants with anky-

loglossia: Eect on milk removal and sucking mechanism

as imaged by ultrasound. Pediatrics 2008;122(1):e188-e194.

60. Segal L, Stephenson R, Dawes M, Feldman P. Prevalence,

diagnosis, and treatment of ankyloglossia. Can Fam

Physician 2007;53(6):1027-33.

61. Boutsi EZ, Tatakis DN. Maxillary labial frenum attach-

ment in children. Int J Paediatr Dent 2011;21(4):284-8.

62. Kotlow L. Diagnosing and understanding the maxillary

lip-tie (superior labial, the maxillary labial frenum) as it

relates to breastfeeding. J Hum Lact 2013;29(4):458-64.

63. O’Callahan C, Macary S, Clemente S. e eects of oce-

based frenotomy for anterior and posterior ankyloglossia

on breastfeeding. Int J Pediatr Otorhinolaryngol 2013;77

(5):827-32.

64. Finigan V, Long T. The effectiveness of frenulotomy on

infant-feeding outcomes: A systemic literature review. Evid

Based Midwifery 2013;11(2):40-5.

65. Webb AN, Hao W, Hong P. The effect of tongue-tie

division on breastfeeding and speech articulation: A sys-

tematic review. Int J Pediatr Otorhinolaryngol 2013;77

(5):635-46.

66. Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM.

Facts and myths regarding the maxillary midline frenum and

its treatment: A systematic review of the literature.

Quintessence Int 2013;44(2):177-87.

67. Devishree G, Gujjari SK, Shubhashini PV. Frenectomy:

A review with the reports of surgical techniques. J Clin

Dent Res 2012;6(9):1587-92.

68. Kaban L, Troulis M. Intraoral soft tissue abnormalities.

In: Pediatric Oral and Maxillofacial Surgery. Philadelphia,

Pa.: Saunders; 2004:147-53.

69. Shetty K, Trajtenberg C, Patel C, Streckfus C. Maxillary

frenectomy using a carbon dioxide laser in a pediatric

patient: A case report. Gen Dent 2008;56(1):60-3.

70. Olivi G, Chaumanet G, Genovese MD, Beneduce C,

Andreana S. Er,Cr:YSGG laser labial frenectomy: A clinical

retrospective evaluation of 156 consecutive cases. Gen

Dent 2010;58(3):e126-33.

71. Kupietzky A, Botzer E. Ankyloglossia in the infant and

young child: Clinical suggestions for diagnosis and man-

agement. Pediatr Dent 2005;27(1):40-6.

72. Hogan M, Wescott C, Griths M. Randomized, controlled

trial of division of tongue-tie in infants with feeding

problems. J Paediatr Child Health 2005;41(5-6):246-50.

73. Díaz-Pizán M, Lagravère M, Villena R. Midline diastema

and frenum morphology in the primary dentition. J Dent

2006;26(1):11-14.

References continued on the next page.

536 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY

BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

74. Gontijo I, Navarro R, Haypek P, Ciamponi A, Hadda A. e

applications of diode and Er:YAG lasers in labial frenec-

tomy in infant patients. J Dent Child 2005;72(1):10-5.

75. Kara C. Evaluation of patient perceptions of frenectomy: A

comparison of Nd:YAG laser and conventional techniques.

Photomed Laser Surg 2008;26(2):147-52.

76. Kleinman DV, Swango PA, Pindborg JJ. Epidemiology of

oral mucosal lesions in United States school children:

1986-87. Community Dent Oral Epidemiol 1994;22(4):

243-53.

77. Shulman JD. Prevalence of oral mucosal lesions in children

and youths in USA. Int J Pediatr Dent 2005;15(2):89-97.

78. Melrose RJ, Handlers JP, Kerpel S, Summerlin DJ, Tomich

CJ. The use of biopsy in dental practice. The position of

the American Academy of Oral and Maxillofacial Pathol-

ogy. Gen Dent 2007;55(5):457-61.

79. Rethman M, Carpenter W, Cohen E, et al. Evidence-based

clinical recommendations on screening for oral squamous

cell carcinomas. J Am Dent Assoc 2010;141(5):509-20.

80. Kazanowska K, Halon A, Radwan-Oczko M. The role

and application of exfoliative cytology in the diagnosis of

oral mucosa pathology – Contemporary knowledge with

review of the literature. Adv Clin Exp Med 2014;23(2):

299-305.

81. American Academy of Oral and Maxillofacial Pathology.

Submission policy on excised tissue. Available at: “http://

www.aaomp.org/wp-content/uploads/2016/12/Policy_on_

Excised_Tissue-Final-11-9-2013.pdf”. Accessed July 25,

2020.

82. Hong C, Dean D, Hull K, et al. World workshop on oral

medicine: VII: Relative frequency of oral mucosal lesions in

children, a scoping review. Oral Diseases 2019;25(Suppl.

1)193-203.

83. Flaitz CM. Differential diagnosis of oral lesions and

developmental anomalies. In: Nowak AJ, Christensen

JR, Mabry TR, Townsend JA, Wells MH, eds. Pediatric

Dentistry: Infancy through Adolescence. 6th ed. Philadel-

phia, Pa.: Elsevier; 2019:8-49.

84. Hays P. Hamartomas, eruption cysts, natal tooth, and

Epstein pearls in a newborn. ASDC J Dent Child 2000;

67(5):365-8.

85. Aldred MJ, Cameron AC, Georgiou A. Pediatric oral medi-

cine and pathology and radiology. In: Cameron AC,

Widmer RP, eds. Handbook of Pediatric Dentistry. 4th ed.

Philadelphia, Pa.: Mosby Elsevier; 2013:209-68.

86. Lapid O, Shaco-Levey R, Krieger Y, Kachko L, Sagi A.

Congenital epulis. Pediatrics 2001;107(2):E22.

87. Marakoglu I, Gursoy U, Marakoglu K. Congenital epulis:

Report of a case. ASDC J Dent Child 2002;69(2):191-2.

88. Neville BW, Damm DD, Allen CM, Chi AC. Soft tissue

tumors. In: Oral and Maxillofacial Pathology. 4th ed. St.

Louis, Mo.: Elsevier; 2016:473-515.

89. Neville BW, Damm DD, Allen CM, Chi AC. Odontogenic

cysts and tumors. In: Oral and Maxillofacial Pathology.

4th ed. St. Louis, Mo.: Elsevier; 2016:632-89.

90. Regezi JA, Sciubba JJ, Jordan RC. Cysts of the jaws and

neck. In: Oral Pathology: Clinical-Pathologic Correlations.

7th ed. St. Louis, Mo.: Elsevier; 2017:245-68.

91. McDonald JS. Tumors of the oral soft tissues and cysts

and tumors of bone. In: Dean JA, ed. McDonald and

Avery’s Dentistry for the Child and Adolescent. 10th ed.

St. Louis, Mo.: Elsivier; 2016:603-26.

92. Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal

and neonatal teeth: Review of the literature. Pediatr Dent

2001;23(2):158-62.

93. Leung A, Robson W. Natal teeth: A review. J Natl Med

Assoc 2006;98(2):226-8.

94. Galassi MS, Santos-Pinto L, Ramalho T. Natal maxillary

primary molars: Case report. J Clin Pediatr Dent 2004;

29(1):41-44.

95. Stein S, Paller A, Haut P, Mancini A. Langerhans cell histio-

cytosis presenting in the neonatal period: A retrospective

case series. Arch Pediatr Adolesc Med 2001;155 (7):778-83.

96. Slayton RL. Treatment alternatives for sublingual traumatic

ulceration (Riga-Fede disease). Pediatr Dent 2000;22(5):

413-4.

97. Rushmah M. Natal and neonatal teeth: A clinical and histo-

logical study. J Clin Pediatr Dent 1991;15(4):251-3.

98. Centers for Disease Control and Prevention. What is

vitamin K deficiency bleeding? Available at: “https://

www.cdc.gov/ncbddd/vitamink/facts.html”. Accessed July

25, 2020.

99. Flaitz CM, Haberland C. Oral pathology and associated

syndromes. In: Nowak AJ, Casamassimo PS, eds. The

Handbook: Pediatric Dentistry. 5th ed. Chicago, Ill.: Amer-

ican Academy of Pediatric Dentistry; 2018:46-100.

100. Regezi J, Sciubba J, Jordan R. Salivary gland diseases. In:

Oral Pathology: Clinical-Pathologic Correlations. 7th ed.

St. Louis, Mo.: Elsevier; 2017:185-224.

101. Neville BW, Damm DD, Allen CM, Chi AC. Salivary

gland pathology. In: Oral and Maxillofacial Pathology.

4th ed. St. Louis, Mo.: Elsevier; 2016:422-72.

102. Regezi J, Sciubba J, Jordan R. Verrucal-papillary lesions.

In: Oral Pathology: Clinical-Pathologic Correlations. 7th

ed. St. Louis, Mo.: Elsevier; 2017:148-60.

103. Neville BW, Damm DD, Allen CM, Chi AC. Epithelial

pathology In: Oral and Maxillofacial Pathology. 4th ed.

St. Louis, Mo.: Elsevier; 2016:331-421.

104. Regezi J, Sciubba J, Jordan R. Connective tissue lesions.

In: Oral Pathology: Clinical-Pathologic Correlations. 7th

ed. St. Louis, Mo.: Elsevier; 2017:161-84.

105. Neville BW, Damm DD, Allen CM, Chi AC. Allergies

and immunologic diseases. In: Oral and Maxillofacial

Pathology. 4th ed. St. Louis, Mo.: Elsevier; 2016:303-30.

106. Regezi J, Sciubba J, Jordan R. Ulcerative conditions. In:

Oral Pathology: Clinical-Pathologic Correlations. 7th ed.

St. Louis, Mo.: Elsevier; 2017:23-79.

107. Neville BW, Damm DD, Allen CM, Chi AC. Periodontal

disease. In: Oral and Maxillofacial Pathology. 4th ed. St.

Louis, Mo.: Elsevier; 2016:140-63.

108. Regezi J, Sciubba J, Jordan R. Red-blue lesions. In: Oral

Pathology: Clinical-Pathologic Correlations. 7th ed. St.

Louis, Mo.: Elsevier; 2017:114-33.